By: Ehyreen Pinto
Para leer el articulo en español: https://acortar.link/XDjMk8
Starting in 2025, new federal regulations go into effect affecting enrollment periods and plan changes for dual beneficiaries (people with Medicare and Medicaid) and for those receiving the low-income subsidy (LIS, known as "Extra Help" from Medicare Part D). These changes are intended to improve the integration of coverage and reduce the number of unnecessary plan changes.
New enrollment rules for dual beneficiaries and LIS
Changes in the frequency of plan changes
Before 2025, dual and LIS beneficiaries could change plans up to three times a year, once per quarter for the first three quarters. These options have now been modified to allow more specific settings:
- SEP Dual/LIS (monthly for medication coverage): Allows dual and LIS beneficiaries to change their drug coverage once a month. This means they can choose to leave a Medicare Advantage plan and move to Original Medicare with a Part D drug plan (PDP), or switch between different PDP plans based on their needs.
- Integrated Care SEP (monthly for integrated plans): Applies to dual beneficiaries with full Medicaid, allowing them to enroll in a special Medicare Advantage D-SNP (Dual Eligible Special Needs Plan) plan or switch between integrated D-SNP plans to align their Medicare coverage with their Medicaid.
These changes allow greater flexibility for those who need to adjust their drug coverage or seek better integration with Medicaid.
Expanding Eligibility for Extra Help (LIS)
Starting in 2024, thanks to the Inflation Reduction Act, more people can access Extra Help. Now, those with incomes up to 150% of the federal poverty level can receive full LIS, meaning more beneficiaries have access to $0 Part D premiums and deductibles and reduced drug copays.
This also means more people have access to the monthly SEP to change their drug coverage when they need to.
Medicare Advantage Integration with Medicaid
To encourage better coordination between Medicare and Medicaid, the 2025 changes establish new rules:
- Some D-SNP plans can now only enroll people who are also enrolled in the same company or parent organization's Medicaid plan.
- In certain states, a beneficiary who has Medicaid with a specific insurer will only be able to enroll in that same insurer's D-SNP, avoiding frequent switching between companies without integration.
- The number of D-SNP plans that an insurer can offer in the same area has been limited to avoid confusion among beneficiaries.
These adjustments seek to ensure that dual beneficiaries receive medical care in a more coordinated and uninterrupted manner.
Importance of Medicaid Recertification
With the elimination of Medicaid continuity policies implemented during the pandemic, many beneficiaries have had to recertify their eligibility. Losing Medicaid means losing “dual” status, affecting eligibility for LIS and D-SNP plans.
If a beneficiary loses Medicaid, a Special Enrollment Period (SEP) is triggered, allowing them to change their Medicare coverage. However, if you do not use this SEP on time, your ability to change plans will be restricted until the next annual enrollment window.
Conclusion
The new 2025 regulations seek to improve the stability and protection of dual and LIS beneficiaries. They now have more options to change their drug coverage or integrate with Medicaid, but with restrictions on Medicare changes to avoid ongoing disruptions to their health care.
For agents, this means they will need to make sure they recommend the right plan from the start and ensure their dual and LIS customers understand their enrollment options. With these changes, it is expected that beneficiaries will receive more stable coverage that is better integrated with their health needs.
Official sources:
- Centers for Medicare & Medicaid Services (CMS)
- Medicare Learning Network
- Medicare.gov
- Inflation Reduction Act
- Healthfirst
